Hysterectomy in obese patients: special considerations

Prevalence and determinants of hysterectomy in India

Increase in the prevalence of hysterectomy among low-and middle-income countries (LMICs) such as India has become a significant concern. Reports based on either a particular group or region show an increasing trend in hysterectomy, but there is a dearth of national-level data in this domain. Hence, there seems to be an urgent need to garner evidence on the prevalence and determinants of hysterectomy, which could pave the way for future programs and policies. We aimed to estimate the prevalence of hysterectomy and assess its determinants using a nationally representative sample. An observational analysis was conducted using data from Longitudinal Aging Study in India (LASI), 2017-2018. 38,154 women aged > 18 years were included. A multivariable logistic regression, presented as an adjusted odds ratio (AOR) with a 95% confidence interval (CI), was used to predict the association between various socio-demographic characteristics and hysterectomy. A separate multivariable logistic regression model was executed to determine the association between selected non-communicable diseases (NCDs) and hysterectomy. Survey weights compensated the complex study design. The overall prevalence of hysterectomy was around 11.35%. Excessive menstrual bleeding followed by fibroids emerged as the leading causes of hysterectomy. The various determinants of hysterectomy were urban residents [AOR: 1.54 (1.21-1.96)], other backward class [AOR: 2.19 (1.72-2.78], working women [AOR: 1.19(1-1.42)] and the most affluent (rich) group [AOR: 2.06 (1.62-2.63)]. Hysterectomy was associated with cancer [AOR: 4.83 (2.51-9.29)], diabetes [AOR: 1.79 (1.25-2.57)], hypertension [AOR: 1.48 (1.27-1.71)] and joint diseases [AOR: 1.43 (1.09-1.88)]. Hysterectomy is considerably prevalent in India, which cannot be overlooked. Health promotion regarding hysterectomy and its implications is needed especially among urban residents, affluent groups and those with a higher body mass index. Health programmes aimed at women should follow a life course approach by prioritizing health and overall well-being even after reproductive years.

vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE

To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30.

DESIGN

A retrospective cohort study.

SETTING

A French teaching hospital.

PATIENTS

All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma).

INTERVENTIONS

Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m²). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management.

MEASUREMENTS AND MAIN RESULTS

A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150).

CONCLUSION

The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Differences in the Active Endometrial Microbiota across Body Weight and Cancer in Humans and Mice

Simple Summary

Of all cancers, endometrial cancer has the greatest association with obesity. Obesity causes dysbiosis of intestinal microbiota, but little is known about whether obesity is associated with dysbiosis of the female genital tract. Therefore, the aim of this study was to determine whether obesity and cancer were associated with altered microbiota profiles in the endometrium. 16S rRNA transcript amplicon sequencing (which captures actively replicating bacteria) of endometrial tissues showed that obesity and cancer were associated with the prevalence of microbial community types in the human endometrium. However, obesity was not associated with microbial community types in the mouse endometrium. The presence of endometrial cancer (but not obesity) was associated with decreased abundance of the Lactobacillus genus in the human endometrium. In mice, an enrichment of Lactobacillus was associated with lower prevalence of disease (normal uterine histology). These results suggest that obesity and cancer may influence microbiota community types in the endometrium (at least in humans) and Lactobacillus may be protective in the endometrium. This study therefore supports further research into the role of microbiota in endometrial cancer development.

Abstract

Obesity is a risk factor for endometrial cancer. The aim of this study was to determine whether actively replicating microbiota in the endometrium differ between obese vs. lean and cancer vs. benign states. We performed 16S rRNA amplicon sequencing on endometrial tissues from lean and obese women with and without endometrial cancer, and lean and obese mice. Results displayed human endometrial microbiota clustered into three community types (R = 0.363, p = 0.001). Lactobacillus was dominant in community type 1 (C1) while community type 2 (C2) had high levels of Proteobacteria and more cancer samples when compared to C1 (p = 0.007) and C3 (p = 0.0002). A significant increase in the prevalence of the C2 community type was observed across body mass index and cancer (χ² = 14.24, p = 0.0002). The relative abundance of Lactobacillus was lower in cancer samples (p = 0.0043), and an OTU with 100% similarity to Lactobacillus iners was enriched in control samples (p = 0.0029). Mouse endometrial microbiota also clustered into three community types (R = 0.419, p = 0.001) which were not influenced by obesity. In conclusion, obesity and cancer are associated with community type prevalence in the human endometrium, and Lactobacillus abundance is associated with normal uterine histologies in humans and mice.

Percutaneous-Assisted versus Laparoscopic Hysterectomy: A Prospective Comparison

OBJECTIVE

To evaluate the feasibility of percutaneous approach, we prospectively compared our experience in percutaneous-assisted hysterectomy (PSS-H) with that in a series of laparoscopic hysterectomies (LPS-Hs).

METHODS

In this multicentric cohort study, from May 2015 to October 2017, 160 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive surgery (MIS): 80 patients received PSS-H and 80 LPS-H. In each group, 30 cases of low-/intermediate-risk endometrial cancer were enrolled. For both groups, we documented preoperative outcomes, postoperative pain, and cosmetic outcomes.

RESULTS

No statistically significant differences were noted in baseline characteristics or operative time. We observed significant differences in estimated blood loss: median of 50 cc (PSS-H) and 100 cc (LPS-H) (p = 0.0001). In LPS-H, we reported 4 (5.0%) intraoperative complications and 1 (1.3%) in PSS-H. Thirty-day complications were 4 (5%) in PSS-H and 11 (13.8%) in LPS-H (p = 0.058). No significative differences were found in visual analog scale score, despite a relevant disparity in cosmetic outcome (p = 0.0001). For oncological cases, the 2 techniques had comparable intra- and postoperative outcomes and oncological accuracy.

CONCLUSIONS

In this study, we reported that PSS-H is comparable to LPS-H for intra- and perioperative outcomes and postoperative pain, while PSS-H seems to be superior in cosmetic outcomes and patient satisfaction. PSS-H may represent a valid alternative in ultra-MIS for benign gynecological conditions and low-/intermediate-risk endometrial cancer.

Hysterectomy in very obese and morbidly obese patients: a systematic review with cumulative analysis of comparative studies

PURPOSE

Some studies suggest that also regarding the patient with a body mass index (BMI) ≥35 kg/m(2) the minimally invasive approach to hysterectomy is superior. However, current practice and research on the preference of gynaecologists still show that the rate of abdominal hysterectomy (AH) increases as the BMI increases. A systematic review with cumulative analysis of comparative studies was performed to evaluate the outcomes of AH, laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) in very obese and morbidly obese patients (BMI ≥35 kg/m(2)).

METHODS

PubMed and EMBASE were searched for records on AH, LH and VH for benign indications or (early stage) malignancy through October 2014. Included studies were graded on level of evidence. Studies with a comparative design were pooled in a cumulative analysis.

RESULTS

Two randomized controlled trials, seven prospective studies and 14 retrospective studies were included (2232 patients; 1058 AHs, 959 LHs, and 215 VHs). The cumulative analysis identified that, compared to LH, AH was associated with more wound dehiscence [risk ratio (RR) 2.58, 95 % confidence interval (CI) 1.71-3.90; P = 0.000], more wound infection (RR 4.36, 95 % CI 2.79-6.80; P = 0.000), and longer hospital admission (mean difference 2.9 days, 95 % CI 1.96-3.74; P = 0.000). The pooled conversion rate was 10.6 %. Compared to AH, VH was associated with similar advantages as LH.

CONCLUSIONS

Compared to AH, both LH and VH are associated with fewer postoperative complications and shorter length of hospital stay. Therefore, the feasibility of LH and VH should be considered prior the abdominal approach to hysterectomy in very obese and morbidly obese patients.